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Pre-operative, I ntra-operative

and post-operative Evaluation

related Systemic Diseases;

I nitial Assesment

T. Realsyah Renardi


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y

The preoperative evaluation consists of gathering

information about the patient and formulating ananesthetic plan. The overall objective is reduction ofperioperative morbidity and mortality.

Inadequate preoperative planning and errors inpatient preparation are the most common causes ofanesthetic complications.

Anesthesia and elective surgery should not proceeduntil the patient is in optimal medical condition.


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If any procedure is performed without

the patient's consent, the physicianmay be liable for assault and battery.

The intra-operative anesthesia recordsserves many purposes. It functions as

a useful intraoperative monitor, a

reference for future anesthetics for thatpatient, and as a tool for quality

assurance.


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Routine Pre-operative Anesthetic

Evaluation

I- His to ry :-

1- Current problem2- Other known problems

3- Medication history

4- Previous anesthetics ; surgery &obstetric deliveries.

5- Family history.

6- Last oral intake.


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7- Review of organ systems:-

General ( including activity level ).

Respiratory.

Cardiovascular.

Renal.GIT.

Hematological.

Neurological.Psychiatric.

Endocrinal.

..


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Preoperative management

Areas to investigate inpreop history.

Previous adverse

responses related toanesthesia

Allergic Reactions

Sleep apnea

Prolonged skeletal muscleparalysis

Delayed awakeningNausea and vomiting

Adverse responses inrelatives

Central NervousSystemCerebrovascular insufficiency

Seizures

Cardiovascular SystemExercise Tolerance

Angina

Prior MI

HTN

Claudication


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LungsExercise Tolerance

Dyspnea and Orthopnea

Cough and Sputum Production

Cigarette consumption

PneumoniaRecent upper resp. tract

infection

LiverAlcohol Consumption

Hepatitis

Kidneys

Nocturia

Pyuria

Skeletal and Muscular

Systems

Arthritis

Osteoporosis

Weakness


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Endocrine SystemDiabetes mellitus

Thyroid gland dysfunction

Adrenal gland dysfunction

CoagulationBleeding tendency

Easy bruising

Hereditary coagulopathies

Reproductive System

Menstrual History

STDs

DentitionDentures

Caps


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II- Phys ical Examination

Vital signs.

Airway.Heart.

Lungs.

Extremities.Neurological Examination.


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Physical Exam:

CNS

Level of ConsciousnessEvidence of peripheral,

sensory or skeletal muscle

dysfxn

CVAuscultation of heart

Systemic blood pressure

Peripheral pulses

VeinsPeripheral edema

Lungs

Auscultation of LungsPattern of breathing


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Upper Airway

Cervical spine mobility

Temporomandibular mobility

Tracheal mobilityProminent central incisors

Diseased or artificial teeth

Ability to visualize uvula

Thyromental distance


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III- Laboratory Evaluation

Hematocrite or Hemoglobinconcentration :

- All menstruating women.

- All patients over 60 years.- All patients who are likely to

experience significant blood loss & may

require transfusion.Serum glucose & Creatinine.

ECG & Chest X-ray.


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Lab TestCXR

ECG

Clinical indicationsPneumonia, pulmonary

edema,

Atelectasis,mediastinal or

pulmonary masses,pulm.HTN,cardiomegaly, Advanced

COPD with blebs, PE

Hx of CAD,Age > 50, HTN,

chest pain, CHF, diabetes,

PVD, SOB, DOE,palpitations,

murmurs


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Lab test

LFT

Renal fxn testing

ClinicalIndicationsHx of Hepatitis, Cirrhosis,portal HTN, GB or biliary

tract disease, Jaundice

HTN, increased fluidoverload, diabetes,

urinary problems, dialysispts


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Lab Test

CBC

Coagulation testing

Pregnancy testing

Clinical IndicationsHematologic disorder,bleeding, malignancy,

Chemo/radiation tx, renal ds.,

highly invasive or trauma sx.

Bleeding disorder hx.,Anticoagulant meds, Hepaticds.

Sexually active, time of lastmenstrual period.


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IV- ASA Classif icat ionThe American Society of Anesthesiologists(ASA) physical

status classification serves as a guide, to allow communication

among anesthesiologists about clinical conditions of patients.A way to predict their anesthetic/surgical risks -the higher ASA

class, the higher the risks.

Class Definition

1 A normal healthy patient.

2 A patient with mild systemic disease & no

functional limitation.

3 Moderate to severe systemic disease that

result in some functional limitation.

4 severe systemic disease that is a constant

threat to life and functionally incapacitating.


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IV- ASA Classif icat ion ( continued )

Class Definition

5 A patient who is not expected to survive 24

hours with or without surgery.

6 A brain-dead patient whose organs are being

harvested.

E If the procedure is an emergency, thephysical status is followed by E.


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ASA Classification &

preoperative mortality rates

Class Mortality Rate

1 0.060.08 %

2 0.270.4 %

3 1.84.3 %

4 7.823 %

5 9.451 %


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The Anesthetic Plan

1 - Pre-medication.

2 - Types of Anesthesia :-

* General

* Local or Regional anesthesia

* Monitored Anesthesia Care3 - Intra-operative management.

4 - Post-operative management.


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Types of Anesthesia

General :

Airway management.

Induction

MaintenanceMuscle Relaxation


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Local or Regional :

Technique.

Agents.

Mon itored Anesthesia Care :

Supplemental Oxygen.

Sedation.


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Intra-operative management

Monitoring.

Positioning.

Fluid Management.

Special Techniques.


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Post-operative management

Pain control.

Intensive Care :

- Post-operative Ventilation.

- Hemodynamic Monitoring.


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Postoperative Complications

Pulmonary

- Pneumonia, atelectasis ,fever,

leukocytosis,

- Respiratory failure/mechanical

ventilation

- Pulmonary embolism


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Cardiovascular

- Anemia- Arrhythmias

- Ischemia

- Air embolism- Hypotension/hypertension

- DVT (both lower and upper limb


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Neurological- Stroke

- Psychosis

Cerebrospinal fluid CSF leak

Bone flap infection Infection, sepsis

Neuropraxia, pressure areas (eg fromcompression while on operating table)

Neurological deterioration eg weakness

arachnoiditis

Wound, lines, others


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Gastrointestinal

Constipation

- Constipation is an inability to move the bowels

(defecate) for many days.

- Associated with bowel paralysis with stasis of intestinal

contents, interfering with normal digestion and nutrient

absorption.

Vomiting

is a dangerous in patients with depressed consciousnesswho are at risk for inhaling (aspirating) their stomachcontents and developing a chemical pneumonitis that all

too frequently progresses to pneumonia


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Others

Fever

Many patients have fevers (are "febrile")

in the first 24 to 48 hours following

- Neurosurgery (brain, spine, or nerve)

- Decubitus ulcers

- Musculoskeletal issues eg shoulder

pain, contractures


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Is anesthesia safe?

Like airplane?

Anesthesia related deaths:

1940 1/10001970 1/10 000

1995 1/250 000

2005 ?


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Safety of anesthesia

1950 - 25 000deaths during 108 hours ofanesthesia

2000 - 500deaths during 108

hours ofanesthesia

Airplane risk (very low) -5deaths during

108

hours of flightRisk of anaesthesia: 100 x higher


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6/6/05 Copyright Quarnstrom Donaldson

Mortality from Anesthesia 1970-1979 U. K.Mortality from Anesthesia 1970-1979 U. K.

Dentists 1:260,000

Physicians 1:248,000

Single Operator / Anesthetist 1:143,000

One Operator One Anesthetist 1:598,000

Conscious sedation 1:1,000,000

(patient died on a motorcycle later the same day)

Dentists 1:260,000

Physicians 1:248,000

Single Operator / Anesthetist 1:143,000

One Operator One Anesthetist 1:598,000

Conscious sedation 1:1,000,000

(patient died on a motorcycle later the same day)

Dionne, Pharmacologic Considerations in Training of Dentists inAnesthesia and Sedation, Anes Prog 36:113-116 1989

note - this study was pre pulse oximeter useagenote - this study was pre pulse oximeter useage


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The Spectrum of Anesthesia

Normal

Anxiolysis

ConsciousSedation

Deep

Sedation GeneralAnesthesia

1. Protective reflexes intact

Patient can independently

and continuously maintain

an airway

Patient can respond

appropriately to verbal

commands

2. Partial loss of

protective reflexes

Inability to

independently maintain

an airway

May not respond to

verbal commands

3. Loss of protective

reflexes

Inability to independently

maintain an airway

No pain sensation or reflex

withdrawal from stimuli

Total unconsciousness


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Risks of Anesthesia

low

high

N20

Anxiolysis

Local

Anesthesia

ModerateSedation

Deep

Sedation

General

Anesthesia


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AGE VS ANESTHETIC-INDUCED,

CARDIAC ARREST / DEATH

AGE VS ANESTHETIC-INDUCED,

CARDIAC ARREST / DEATH

> 60> 60

incidence

rate

incidence

rate

1-101-10 11-2011-20 21-3021-30 31-4031-40 41-6041-60< 1< 1

0.010.01

0.020.02

0.030.03

0.040.04

0.050.05

Marx, Anes ., 39:54-58, 1973Marx, Anes ., 39:54-58, 1973


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age range = 21 mo. - 59 yr.age range = 21 mo. - 59 yr.

00

11

22

33

44


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age range = 21 mo. - 59 yr.age range = 21 mo. - 59 yr.

00

11

22

33

44


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Standards for Conscious Sedation

Level 1 minimal sedation - Anxiolysis

Level 2 Moderate Sedation/Analgesia -

Conscious Sedation

Level 3 Deep Sedation/Analgesia

Level 4 Anesthesia


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Level 1 minimal sedation - AnxiolysisA drug-induced state during which patients respondnormally to verbal commands. Although cognitive functionand coordination may be impaired, ventilatory andcardiovascular functions are unaffected.

Level 2 Moderate Sedation/Analgesia -Conscious Sedation

Level 3 Deep Sedation/AnalgesiaLevel 4 Anesthesia


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Level 1 minimal sedation - AnxiolysisLevel 2 Moderate Sedation/Analgesia -Conscious Sedation

A drug-induced depression of consciousness during which

patients respond purposefully to verbal commands, eitheralone or accompanied bylight tactile stimulation. Nointerventions are required to maintain a patient airway andspontaneous ventilation isadequate. Cardiovascular

function is usually maintained.Level 3 Deep Sedation/AnalgesiaLevel 4 Anesthesia


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Level 1 minimal sedation - AnxiolysisLevel 2 Moderate Sedation/Analgesia -Conscious Sedation

Level 3 Deep Sedation/AnalgesiaA drug-induced depression of consciousness during whichpatients cannot be easily aroused but respond purposefullyfollowing repeated or painful stimulation. The ability toindependently maintain ventilatory function may be

impaired. Patients may require assistance in maintaining apatent airway, and spontaneous ventilation may beinadequate. Cardiovascular function is usually maintained.

Level 4 Anesthesia


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Joint Commission on Accreditation of HealthcareOrganizations (JCAHO)

Level 1 - None

Level 2 - conscious sedation - pulse oximeter andBlood Pressure, ability to resuscitate.Monitoring YES

Patient assessment - ASA status YES - 1 OR 2

Staff - someone is always with the patient YESEquipment YES

Informed consentYESCompetent at least one level greater than where

you normally practice if patients slip into next levelResek, Jayne, MS RN, Anesthesia Today vol.11 No. 2 Fall 2000 p. 2


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Pain

Unpleasant sensory and emotionalexperience associated with actual orpotential tissue damage

Injection of local anesthetic agents,corticosteroids, opiates, and

neurolytic agents around nerves canrelieve pain.


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Advantages

Reduced postoperative analgesiarequirements

Reduced duration at the hospital

Greater patient satisfaction

Examples Use of continuous femoral nerve block expedites

rehabilitation efforts Early ambulation and discharge with decreased side effects

of N/V, drowsiness .


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Advantages

Suitable for older and multimorbid patients

Few side effects

Easier monitoring

Continuous nerve block

Suitable for nonoperative cases


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Advantages

Fewer complications related to pain:

Tachycardia, hypertension, increasedperipheral vascular resistance

increased myocardial oxygenconsumption

Decreased intestinal motility

postoperative ileus

Decreased vital capacity and FRC withthoracic and abdominal procedures


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Limitations

Additional time is requiredforinduction and onset of block

Contraindications

Coagulopathy, neuropathies, anatomicaldeviations, systemic disease or infection

Need experience & cooperative andinformed patient


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Complications Hematoma , infection

Injury or anesthetic blockade of adjacent structures:

injection of anesthetic into epidural or subarachnoid spaceduring brachial plexus block = total spinal

Pneumothorax

Nerve damage Needle trauma or injection into nerve

Systemic local anesthetic toxicity, allergy Tachycardia and hypertension (epinephrine), tinnitus, metallic

taste in mouth, perioral numbness, seizures, cardiovascular &CNS depression


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Symptoms of lidocaine toxicity

5

10

15

20

25

ConvulsionsUnconsciousnessMusclar twitchingVisual disturbanceLightheadedness

Numbness of tongue

coma

Repiratory arrest

CVS depression

30


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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E

Early history of regional anesthesia

Koller and Gartner

report local anesthesia(1884)

Carl Koller1857 -1944

E l hi f i l h i


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Koller and Gartner


1884 Halsted injectscocaine directly into

mandibular nerve andbrachial plexus

William S. Halsted

E l hi t f i l th i


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Koller and Gartner




1904 Einhorndiscovers procaine

(Novocaine) Procaine

E l hi t f i l th i


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Koller and Gartner




1904 Einhorndiscovers procaine

(Novocaine) 1943 Lofgren

discovers lidocaine(Xylocaine)

Lidocaine

Ch l f l l th ti


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Chronology of local anesthetics

Cocaine Niemann 1860 Ester

Benzocaine Salkowski 1895 Ester

Procaine Einhorn 1904 Ester

Tetracaine Eisler 1928 Ester

Lidocaine Lofgren 1943 Amide

Chloroprocaine Marks, Rubin 1949 Ester

Mepivacaine Ekenstam 1956 Amide

Bupivacaine Ekenstam 1957 AmideRopivacaine Sandberg 1989 Amide

After: Cartwright & Fyhr. Reg Anesth 1988;13:1-12

ff f &


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Effects of medical conditions &

drugs on LA dosing & kinetics

Renal failure: accumulation of metabolic

products

Hepatic failure:amide clearance

Cardiac failure; and H2 blockers: hepaticblood flow and amide clearance

Cholinesterase deficiency or inhibition: ester

clearance Pregnancy: hepatic blood flow; amide

clearance; protein binding


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Is there one common mechanismfor LA-induced cardiac death?

Arrhythmias (bupivacaine)? Left-ventricular depression (lidocaine)?

Resuscitation drug failure (bupivacaine)?

Mechanism probably depends on specificdrug!


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Treatment of LA CV toxicity

Follow ACLS guidelines Substitute amiodarone for

lidocaine

Substitute vasopressin forepinephrine

Consider cardiopulmonary

bypass or lipid infusion ifstandard drugs fail


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Postoperative management

PACU Guidelines

STANDARD I

ALL PATIENTS WHO HAVE RECEIVED GENERALANESTHESIA, REGIONAL ANESTHESIA OR

MONITORED ANESTHESIA CARE SHALL RECEIVE

APPROPRIATE POSTANESTHESIA MANAGEMENT.


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STANDARD IIA PATIENT TRANSPORTED TO THE PACU SHALL BE

ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARETEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT'SCONDITION. THE PATIENT SHALL BE CONTINUALLYEVALUATED AND TREATED DURING TRANSPORT WITHMONITORING AND SUPPORT APPROPRIATE TO THE

PATIENT'S CONDITION.

STANDARD IIIUPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THERESPONSIBLE PACU NURSE BY THE MEMBER OF THE

ANESTHESIA CARE TEAM WHO ACCOMPANIES THEPATIENT


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STANDARD IVTHE PATIENT'S CONDITION SHALL BE EVALUATEDCONTINUALLY IN THE PACU.

STANDARD VA PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OFTHE PATIENT FROM THE POSTANESTHESIA CARE UNIT.


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Discharge Criteria

Post anesthetic discharge scoring (PADS)system is a simple cumulative index thatmeasures the patient's home readiness.

Five major criteria: (1) vital signs, includingblood pressure, heart rate, respiratory rate, and

temperature; (2) ambulation and mentalstatus; (3) pain and PONV; (4) surgicalbleeding; and(5)fluid intake/output.

Patients who achieve a score of 9 or greater

and have an adult escort are considered fit fordischarge (or home ready).


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Vital Signs: 2 = Within 20% of the preoperativevalue, 1 = 20%40% of the preoperative value, 0 =40% of the preoperative value

Ambulation: 2 = Steady gait/no dizziness 1 = Withassistance 0 = No ambulation/dizziness

Nausea and Vomiting:2 = Minimal 1 = Moderate0 = Severe

Pain: 2 = Minimal 1 = Moderate 0 = Severe

Surgical Bleeding:2 = Minimal 1 = Moderate 0 =Severe


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Perioperative medications

Take all usual medications Antihypertensives

Beta blockers

Statins

Think about discontinuing/replacing Aspirin

Anticoagulants

Diabetic medications MAOIs


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